A REVIEW OF PROGRESS IN IMPLEMENTATION OF THE COMMISSION ON INFORMATION AND ACCOUNTABILITY FOR WOMEN S AND CHILDREN S HEALTH

A REVIEW OF PROGRESS IN IMPLEMENTATION OF THE COMMISSION ON INFORMATION AND ACCOUNTABILITY FOR WOMEN S AND CHILDREN S HEALTH WHO April 2014 TAJIKISTAN Background and country context In recent years, the Government of Tajikistan, within the framework of achieving Millennium Development Goals (MDGs), has made a number of significant accomplishments. For example, at the beginning of the 1990s only one out of ten women of reproductive age used contraceptive methods to prevent unwanted pregnancies, but by the beginning of 2010 this number had increased to 30%. Similarly, the maternal mortality rate decreased by 60% and the child mortality rate decreased by 45%. At the same time, home deliveries decreased from 48% to 12%, and the under-five mortality dropped from 105 per 1 000 live births in 1990 to 58 in 2012. Despite these achievements, progress towards achieving the MDGs has not been sufficient and more efforts are needed to reach the targets of 17 per 100 000 live births for the maternal mortality ratio, and 35 per 1 000 live births for under five mortality. 1 With this in mind, in 2011 the Government of Tajikistan signed additional commitments to advance the UN Global Strategy for Women s and Children s Health. Despite significant progress since 1990, additional efforts are still required in order for Tajikistan to achieve MDGs 4 and 5. 100 90 Figure 1: Maternal mortality in Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan Maternal deaths per 100 000 live births 80 70 60 50 40 30 20 10 0 Kyrgyzstan Tajikistan Turkmenistan Uzbekistan 1990 2005 2013 Source: WHO, UNICEF, UNFPA, World Bank, United Nations Population Division. Trends in Maternal Mortality: 1990 to 2013. Geneva: World Health Organization; 2014. Purpose and Process The implementation of priority activities in Tajikistan s Country Accountability Framework (CEF) is now well underway. During a multi-country workshop in Kyrgyzstan in October 2012, Tajikistan s delegation completed a self-assessment of the current situation on accountability for health, and developed a draft roadmap to implement the accountability framework according to national needs and priorities. The results of the self-assessment were discussed at a two-day national workshop held in March 2013 with the participation of 36 representatives from various departments of the Ministry of Health and Social Protection (MoHSPP) (MCH Department, Health Policy Analysis Unit, Department for Health Economics, Budget Planning and Projections), leading maternal and child health institutions (National 1 WHO, UNICEF, UNFPA, World Bank, United Nations Population Division. Trends in Maternal Mortality:1990 to 2013. Geneva: World Health Organization; 2014. UNICEF, WHO, World Bank, United Nations Population Division. Levels and Trends in Child Mortality: Report 2013. New York: UNICEF; 2013. 1

A review of progress in implementation of the Commission on Information and Accountability for Women s and Children s Health Centre for Reproductive Health, National Scientific Research Institute for Obstetrics, Gynecology and Perinatology, Tajik State Medical University), the Committee on Women and Family Affairs under the Government of Tajikistan, the Parliament of Tajikistan, the National Agency for Statistics, donor partners (GIZ, USAID, JICA, KfW/EPOS, UNFPA, UNICEF) and civil society organizations (Tajik Family Planning Alliance, Representative of Sexual and Reproductive Health coalition). This assessment 2 and a previously-conducted mapping of partners were used as the basis for finalizing the roadmap for 2013-2015. The timeline below illustrates the main events that mark progress in the country s accountability efforts. European regional workshop October 2012 Figure 2: Timeline of accountability events in Tajikistan National workshop March 2013 Catalytic funds disbursed April 2013 Mid-term assessment May 2014 Tajikistan s roadmap covers all seven areas of the accountability framework: 1) civil registration and vital statistic (CRVS); 2) monitoring of results; 3) maternal death surveillance and response (MDSR); 4) ehealth and strengthening use of ICT; 5) monitoring of resources; 6) national mechanisms for reviews and accountability; and 7) advocacy. Tajikistan requested and received US$ 250 000 to implement the relevant activities. The pie chart below provides a breakdown of the country s prioritization of catalytic funds. Figure 3: Distribution of US$ 250 000 of catalytic funding in Tajikistan (% distribution) ADVOCACY & ACTION 11% RESOURCE TRACKING 14% Ehealth & INNOVATION 9% MONITORING RESULTS 6% REVIEWS 4% CRVS 14% MDSR 42% 2 This mid-term assessment is based on a desk review, workshops and meetings between Government of Tajikistan representatives and development partners. Detailed lists of participants from the workshop and meetings are available upon request. 2

High-level political commitment for RMNCH The Government of Tajikistan s commitment to improving women s and children s health has been demonstreated through the National development strategy of the Republic of Tajikistan to the period 2015. Similarly, the National health strategy of the Republic of Tajikistan 2010-2020 clearly identifies strengthening maternal, newborn, child and adolescent health as one of the main priorities, highlighting the following expected results: targeted free care entitlements; strengthened competencies of, and incentives for, family practitioners; improved transportation networks in support of rural providers; improved diagnostic and curative capacity of rayon-level health care facilities; modernized obstetric/gynecological and neonatal beds in rayon and city hospitals. An analysis of the implementation of the National Reproductive Health Strategic Plan (20014-2014) has started in Tajikistan. WHO and partners assisted in organizing a national workshop in May 2014 to discuss the process, as well as global and regional priorities in the area of reproductive, maternal and child health. In addition, as part of the Global strategy for women s and children s health, the Government of Tajikistan is committed to the following: 85% of midwives will be trained to provide emergency obstetric care; At least 85% of maternity facilities will apply clinical protocols approved by Ministry of Health; youth friendly health services will be expanded from pilot sites to nationwide implementation; 50% of the needs for modern contraceptives will be covered by the national budget; accreditation policy will be developed for maternity institutions; at least 90% of maternity hospitals will be certified. Progress and Challenges General observations: Funding for accountability on women s and children s health in Tajikistan has been truly catalytic; The focus on accountability has revitalized efforts towards reaching MDG 5; The sensitization of the media has been instrumental in focusing the spotlight on RMNCAH issues in the country. Key challenges: The Government of Tajikistan has shown a high level of commitment to improving women s and children s health. Stronger engagement of civil society and Parliament; Scaling up the implementation of tools, technology and methodologies from national and regional levels to local (jamoat) levels; Capacity building at local levels. 3

A review of progress in implementation of the Commission on Information and Accountability for Women s and Children s Health Leveraging catalytic funds to improve women s and children s health The Government of Tajikistan has been successful in leveraging financial and technical support for various activities in all seven domains of the accountability work. Some of the key areas where partners have collaborated with the Government are highlighted below: GIZ: Quality of care and BCC strategy. EU-funded HMIS Project: International Classification of Disease (ICD-10) capacity building and implementation of DHIS-2. JICA: Project for improving maternal and child health care system at the regional level and capacity building on integrated management of childhood illnesses (IMCI). KFW: Capacity-building on effective perinatal care. USAID: Numerous projects including the implementation of the first Demographic and Health Survey. The USAID Quality Health Care Project contributes towards improving quality of care and strengthening MDSR in the country. UNAIDS: Maternal and child health capacity-building activities and advocacy. UNDP: Capacity building of the Ministry of Justice and improved birth registrations. UNFPA: Also contributes to the DHS project and supports the Beyond the numbers initiative. The agency conducts community mobilization campaigns on reproductive health, family planning services, and prevention of mother-to-child transmission of HIV. UNICEF: MICS, the child survival and development programme and the infant mortality causal analysis. Along with UNFPA and USAID, they jointly supported a review of the Law on Reproductive Health and Reproductive Rights of Tajikistan. Russian Federation: Project on improvement of the quality of hospital care for children 2012 2014. WHO: Beyond the numbers initiative. Also provides support to the national package of indicators, resource tracking, the joint annual review and media training. Civil Registration and Vital Statistics (CRVS) Progress: Tajikistan s accountability framework indicates three priority actions in the CRVS and MDSR components: improving quality of statistical data through improving knowledge of ICD-10, improving hospital reporting and building capacity. In preparation for building capacity and improving the quality of health data reporting, a nationallyadapted version of ICD-10 was developed. This is an essential component of the District Health Information Software (DHIS2) currently being used in the country, and is available in both Russian and Tajik languages. Tajikistan developed the training package, a computer programme for searching codes of diseases and causes of death, a computer programme for participants pre/post testing of knowledge and skills, and case studies. A circular letter was issued which obligated all health facilities, regardless of type of ownership, to use the adapted national version of ICD-10 for mortality and morbidity classification and coding, and workshops were organized for 80 health information system specialists across the country. Planning for a comprehensive assessment of the CRVS system was initiated, including identifying the assessment tool and approach, results of previous assessments and current CRVS interventions, a budget template, an activities timeline and next steps for conducting the full CRVS assessment. Challenges: Tajikistan faces a lack of trained staff, especially IT specialists. Furthermore, DHIS2 at this stage is only available at the district level. At the local (jamoat) level, reporting procedures are complicated and causes of death for women and children are often not accurately captured. 4

Monitoring results and use of 11 core indicators Progress: The National Health Strategy for 2010-2020 includes an implementation plan, a monitoring and evaluation matrix and an indicator package. Data are collected and analysed once a year to feed the joint annual reviews (JAR) and health summit. The package covers all health system functions; however, the JAR of the first two years of implementation revealed a number of gaps including the lack of the 11 core RMNCH indicators. The indicator package was subsequently revised in a process that included technical working group meetings under each of the components (involving technical experts from development partner organizations), M&E training for the representatives of the technical working groups, guidance on data collection within the revised indicator package, development of a passport for each of the indicators and a roundtable with high level policy-makers and development partners. The revised indicator package was approved by the MoHSPP in September 2013, and a policy brief on the M&E process was developed for wider use. The revised indicator package, based on international M&E principles, is specific, simple and clear. The number of indicators was reduced from 218 to 99 including 11 impact indicators, 14 outcome indicators, and 74 output indicators, grouped by strategy components. Eight of eleven RMNCH indicators were included. It should be noted that for various reasons two core RMNCH indicators, (i) child stunting and (ii) postnatal care, were not included in the package. In addition, the package does not allow for disaggregation by gender and equity factors. These are important considerations for future revisions. Challenges: Data that is not collected routinely will require surveys. Funds for such surveys are not allocated by the Government and support from development partners will be needed. In addition, further capacity building is needed among all levels of staff for data collection, reporting and analysis. Maternal Death Surveillance and Response (MDSR) Progress: In 2008, Tajikistan introduced the two WHO Beyond the Numbers (BTN) approaches, Confidential Enquiry into Maternal Deaths (CEMD) at the national level, and Near-Miss Case Reviews (NMCR) at facility level. Since that time, there was a turnover of national staff and implementation of these methodologies was suspended. To address this issue, a country plan for strengthening MDSR was developed in 2013. Several capacity-building activities were carried out, including a national workshop to review progress in BTN implementation, training on the NMCR methodology for over 80 health care providers, and cross-visits and monitoring/supervisory visits. Twenty regional coordinators were trained in use of the review MDSR in Tajikistan is moving away from a culture of blame towards one of understanding causes of death. questionnaire and CEMD methodology. In addition, the MoHSPP, with support from partners, has been strengthening national research capacity to make new evidence on sexual and reproductive health available for decision-making. Due to these efforts, data were collected and are under analysis on 67 officially registered maternal deaths that occurred in 2013. The first national CEMD report is in progress and will be presented at the national BTN workshop. Furthermore, efforts to improve confidentiality have improved. Most importantly, there is overall agreement that the system is moving away from a culture of blame towards one of understanding the causes of death. Challenges: Despite the gains made, Tajikistan still has several issues to tackle in this area, including the need for further capacity building and dissemination of information. This is particularly important in light of the overall challenges that face the country in terms of maternal mortality. 5

A review of progress in implementation of the Commission on Information and Accountability for Women s and Children s Health Innovation and ehealth Progress: In an effort to introduce innovations to the health care system, under the Comprehensive Strategic Plan for the Development of Health Information Systems, the MoHSPP provided Khatlon Oblast clinical hospital with equipment for conducting telemedicine services. This equipment allows telemedicine consultation between doctors to discuss the management of complicated cases and to improve access to quality health services, particularly for populations from remote areas. Challenges: Despite efforts to implement a nation-wide electronic reporting system, the lack of basic infrastructure (e.g., phone lines) in some remote areas is a major barrier. Monitoring of resources Progress: Tajikistan has used national health accounts (NHA) for several years and in 2013 committed to using the System of Health Accounts (SHA) 2011 methodology. The first SHA report with the latest available 2012 data was produced at the end of 2013. RMNCH sub-accounts were also developed and a relevant report completed, showing that from 2007 to 2012, public funding at Reproductive Health Centers had increased in nominal terms from 126,000 to 2.2 million TJS. It also found that, despite the fact that the services provided under the RMNCH Programme are delivered free of charge, the public expenditure share of these services is approximately 36.5% (267 million TJS) of the total expenditure, while the private household share is 62.3% (457 million TJS). Foreign aid covers 1.2 % (8.5 million TJS) of the RMNCH Programme expenditure. The SHA 2012 report was a crucial element in the decision-making process during the 2013 Joint Annual Review. Tajikistani Somoni (TJS) 2500 2000 1500 1000 500 0 126 Source: Tajikistan SHA report, 2013 Figure 4: Public funding for reproductive health 279 292 242 580 453 770 565 1300 2006 2007 2008 2009 2010 2011 2012 847 2188 1348 Nominal terms Real terms Challenges: Institutionalization of SHA into the general health system is still in progress and will be completed during 2014. Further capacity building is needed in this area. National mechanisms for reviews and accountability Despite the fact that many RMNCH services are provided free of charge, out-of-pocket expenditures still remain high. Progress: Tajikistan continues to strengthen its joint annual review mechanism including holding a Health Summit for improved accountability. From October to December 2013, a joint annual review took place to monitor and evaluate the progress of the third year of implementing the National Health Strategy. The review included meetings of the technical working groups for each of the four pillars (governance, service delivery, resource generation and financing); the MoHSPP used data from the revised indicator package, analytical reports, and policy briefs produced by different programmes. Since RMNCH is a priority area, a separate presentation on progress and challenges was given by the head of the MCH department and widely discussed. 6

Following this review, a health summit was carried out in December 2013 with the participation of over 200 representatives from key ministries and agencies, educational institutions and universities, non-governmental organizations, heads of government and private health facilities from regions, and development partners. The summit resulted in a draft action plan for 2014, and a resolution on progress and difficulties experienced in 2013. Challenges: Despite a strengthened review mechanism, the involvement of civil society organizations remains weak. This issue needs to be addressed in future Joint Annual Reviews (JAR). Advocacy Progress: The Government of Tajikistan is increasingly engaging with media in order to draw attention to key health issues. With the support of development partners, the MoHSPP conducted information workshops for 100 representatives of national and regional level media. During the workshops, in addition to health-specific issues - such as reproductive health, family planning, quality antenatal care, home births, special attention to youth, gender, etc. - the role of the media in the proper and accurate coverage of the issues was discussed. Information was broadcast on national and regional radio and TV channels. Furthermore, to increase the participation of Parliament and civil society in RMNCH issues, the MoHSPP, supported by development partners, participated in the training/mock session on preparation for reporting on Convention on the Elimination of all Forms of Discrimination against Women (CEDAW). The capacity-building exercise aimed at enhancing the understanding of state partners (members of the delegation, National Human Rights Institutions, NGOs involved in the preparation of alternative reports and the UN Country team) on CEDAW implementation, monitoring and reporting. Challenges: Despite these efforts, more needs to be done to actively engage Parliamentarians on health related issues, including RMNCH. Moving forward During the mid-term assessment workshop in May 2014, the Government of Tajikistan and partners agreed that an important next step would be to revise the accountability roadmap to better reflect priorities for 2015 and beyond, particularly as the country makes progress towards universal health coverage. In addition, the following specific issues have been identified as key for making progress towards women s and children s health in Tajikistan: Civil registration and vital statistics. As the MoHSPP continues to implement the National Comprehensive Strategic plan for development of health information systems, nation-wide scale-up of capacity building on ICD-10 and quality of data, and strengthening interagency coordination will remain top priorities. Conducting a full CRVS assessment will significantly contribute to improving interagency coordination and quality of vital statistics data. Monitoring of results: In 2014, the MoHSPP plans to include a health module in the integrated household budget survey. The results will provide a baseline for several important indicators. In addition, several operations research activities will be conducted. Maternal death surveillance and response: The National CEMD Committee has made progress on collecting and analyzing maternal death cases. Preliminary results indicate that the structure of maternal death causes is changing from indirect to direct, preventable causes. These findings will require a focus on access and improvement of quality of care for pregnant women and mothers. The first national report on maternal death analysis based on the CEMD methodology is under preparation, and will be launched and discussed with a broad network of involved stakeholders. In addition to NMCR and CEMD methodologies, perinatal audit methodology is being considered. Better integration between primary and hospital maternal and child health services and strengthening of the referral system is one of the priorities for the years to come. Further technical assistance by development partners will be needed to follow up the implementation of the recommendations resulting from the CEMD and NMCR. Assistance has been requested from the inter-agency group (WHO, UNFPA, UNICEF, UNDP and WB) on building capacity of policy makers, 7

A review of progress in implementation of the Commission on Information and Accountability for Women s and Children s Health statisticians and health professionals to better understand the development of the estimates of maternal mortality. Innovation and ehealth: The development of the country s vision and strategy on ehealth is part of the Government s agenda. Specific emphasis will be placed on support for building a strong, effective coordination mechanism for ehealth, improving the infrastructure and broader use of ICT in providing quality health services, specifically: the establishment of call-centers and hot-lines for patients, patient education and information, phone reminders, ICT use for healthy life-style campaigns and development of telemedicine services. Monitoring of resources: The Government, with support from partners, has developed an action/work plan to 2014 for further institutionalize SHA. This includes piloting the developed form for providers, conducting trainings and introducing it for routine use. This will build a foundation for further strengthening the Government s capacity in budget formulation, developing a mid-term expenditure framework, and budgeting for priority programmes and a Basic Benefits Package. National mechanisms for reviews and accountability: The next JAR, planned for the end of 2014, will include a detailed analysis of the RMNCH area. Advocacy: Consultations on the post-2015 agenda demonstrate that maternal and child health issues will remain Government priorities for years to come. The MoHSPP plans to update all strategic RMNCH documents and strengthen advocacy efforts to properly reflect and emphasize maternal and child health issues in all national strategic documents, including the National Development Strategy and the new UNDAF. The MoHSPP will continue to promote the involvement of Parliament, civil society and media in RMNCH issues. 8